Provider Demographics
NPI:1508287673
Name:PCC COMMUNITY WELLNESS CENTER
Entity Type:Organization
Organization Name:PCC COMMUNITY WELLNESS CENTER
Other - Org Name:PCC COMMUNITY WELLNESS CENTER AT LORETTO HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:URSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-383-9786
Mailing Address - Street 1:6201 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1108
Mailing Address - Country:US
Mailing Address - Phone:708-406-3056
Mailing Address - Fax:708-406-3051
Practice Address - Street 1:1 ERIE CT STE 7140
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2510
Practice Address - Country:US
Practice Address - Phone:773-537-0020
Practice Address - Fax:773-537-0029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)